MSN-FNP Musculoskeletal Disorders

A girl fell while holding hands with an adult. Afterwards, she holds her arm in a pronated position and refuses to use her hand or elbow. She is taken to the ER, where the pediatrician is able to reduce the injury manually. What is the most likely diagnosis? A. Osteochondritis dissecans of the capitellum B. Apophyseal avulsion fracture of medial humeral epicondyle C. Subluxation of radial head D. Scaphoid fracture

C. Subluxation of radial head Explanation: Classic presentation of nursemaid's elbow. (A) (B) Osteochondritis dissecans of the capitellum and apophyseal avulsion fracture of the medial humeral epicondyle are associated with Little leaguer's elbow. (D) Scaphoid fracture is the most common fracture of the carpal bones in children, and it does not present this way.

A 7 yo male presents with pain and a moderate amount of knee effusion after being tackled while playing football. No fracture is seen on the plain films of the knee. Which of the following is the appropriate management step? A. Further evaluation is needed when a pediatric patient has joint effusion that may require aspiration and or MRI B. Immobilize knee and reassess the patient in 4 weeks C. Refer to physical therapy D. Begin anti-inflammatories and advice ice

A further evaluation is needed when pediatric patient has joint effusion that may involve joint aspiration and/or MRI

A 7 yo boy presents to his pediatrician with a painless limp. He denies any trauma to his hips or lower extremities but c/o occasional left hip, thigh, and knee pain. His VS are normal and he is afebrile. Exam is significant for atrophy of the left thigh. Which of the following diagnostic test should be ordered first? A. Anteroposterior and frog-leg radiographs of hips B. ESR and C-reactive protein C. Factor V Leiden D. Ultrasound of both hips.

A. Anteroposterior and frog-leg radiographs of hips. Explanation: A painless limp in a 7 yo boy with no history of trauma is strongly suggestive of Legg-Calve-Perthes disease, for which anteroposterior and frog-leg radiographs of the hips are usually diagnostic. MRI and bone scan can sometimes be beneficial in diagnosing early cases of the condition. (B) ESR and C-reactive protein are usually elevated in septic arthritis. )C) Factor V Leiden and other hypercoagulables states are associated with LCPD. (D) Ultrasound of the hips is the test of choice for infants with suspected developmental dysplasia of the hip.

A football player c/o CP after being tackled from the side and rolling on his shoulder. Exam reveals swelling at the sternoclavicular joint but no swelling in his neck or vein engorgement. There is no abnormality viewed on chest plain films. What is the next step in imaging management? A. Chest CT B. Cardiac MRI C. Prone serendipity view D. Sunrise view

A. Chest CT Explanation: sternoclavicular dislocations are a rate injury seen in athletes. They occur as a result of direct trauma (posterior) or an indirect traumatic mechanism (anterior). Anterior dislocations are more common than posterior. Swelling at the joint is commonly seen on physical exam. Other symptoms can include neck vein engorgement in posterior dislocations and arm paresthesia in either type. Plan films can be normal, and additional imaging may be necessary. Chest CT is the next recommended imaging modality to look for a sternoclavicular joint dislocation.

A 23 yo male football player presents with severe pain after an acute injury to his right leg. On exam, he is unable to bear weight on the right side, and his right leg is significantly shorter than the left. The right leg is rotated internally at the hip at rest. Which of the following injuries is likely present? A. Posterior hip dislocation B. Anterior hip dislocation C. Sacroiliac dislocation D. Bursitis of hip

A. Posterior hip dislocation Explanation: About 90% of hip dislocation ae posterior in which the affected limb is shortened and internally rotated. Posterior dislocations with an associated fracture are categorized by the Thompson and Epstein classification system. (B) In an anterior dislocation, the limb will not be shortened as significantly and will be externally rotated. (C) Sacroiliac dislocations would not present with leg rotation or significant limp length changes and would involve pelvic pain. (D) Bursitis of the hip would present with pain in the area of the greater trochanter on the lateral hip.

A 24 yo female tennis player c/o knee pain upon presentation to the orthopedic clinic. During one of her games a month ago, she quickly changed direction to return a served ball from her opponent. She felt an uncomfortable pain twisting motion as she reached for the ball. After the incident, she was able to put weight on her knee and felt fine walking. However, recently she has felt increasing amounts of knee pain when walking, joint-line tenderness, and increasing difficulty putting weight on her knee. VS are normal. BMI is 24. McMurry's test is performed in which the patient feels pain in the knee when it is flexed completely and the examiner provides a valgus stress. Which of the following is the next step in management? A. Conservative management (RICE and NSAIDs) B. MRI of the knee C. X-ray of the knee D. Corticosteroid injection

A. Conservative management (RICE and NSAIDs) Explanation: A meniscus tear usually occur when the knew is twisted flexed with the foot planted on the ground. Unlike ACL, MCK, or LCL tears, there is typically no trauma involved and no immediate pain following the injury. Patients can walk and bear weight on the knee following the injury. However, in the days that follow, they present with symptoms of joint-line tenderness, difficulty squatting, joint effusion, and loss of smooth motion of the knee. Meniscus tears are diagnosed y the McMurry test. If pain is felt the McMurry test is positive. Initial management is conservative therapy. (B) (C) McMurry test confirms the diagnosis of a meniscus tear. No imaging is needed. (D) Steroid injections to not improve the overall condition of the knee in a muscle tear.

A 33 yo woman with PMH of DM complains of mild pain in her wrist. The pain is located along the radial side of the wrist. She denies any loss of sensation or numbness/tingling. She does not exactly when the pain and discomfort started and cannot recall any traumatic or inciting event. VS or normal Exam reveals a well-circumscribed, subcutaneous, soft, mobile wrist mass that is mildly tender to palpitation and transilluminated with lighting. What is the next step in management? A. Conservative treatment (NSAIDs, physical therapy) B. MRI of hand C. Aspiration of mass D. Surgical excision

A. Conservative treatment (NSAIDs, physical therapy) Explanation: A ganglion cyst is a cystic swelling typically found on the dorsal side of the wrist. These are thought to arise due to herniation of synovial tissue from a joint capsule or tendon sheath. They present with chronic wrist pain and may be accompanied by coolness of the hand, numbness/tingling, and possible parenthesis. The mass is mobile, tender, and transilluminates. Most resolve spontaneously and heal within months of conservative treatment.

A 14 year-old female presents for pre-sports physical. She c/o back discomfort when she "sits for a long time." Her exam reveals scoliosis with a left-sided curve. An MRI of the spine is indicated to rule out which of the following conditions? A. Intraspinal syrinx B. Narrowing of disc space C. Schmorl nodes D. Irregularities in vertebral endplates

A. Intraspinal syrinx Explanation: About 80% if scoliosis cases appear as a right thoracic curve. A left sided pattern is associated with risk for intraspinal syrinx or tumor, which can be detected on MRI. The remainder of findings are associated with Schneurmann kyphosis, the 2nd most common cause of spinal deformities in pediatrics. A scoliotic curve must measure greater than or equal to 10 degress on a spinal radiography via the COBB method (a special tool that measures the angle on radiograph) to meet the criteria for diagnosing scoliosis, but most patients do not exhibit clinically significant respiratory symptoms until the curves measure 60 to 100 degrees.

Which of the following reflexes is elicited by allowing he infant's head to move back suddenly (from a few inches off the mattress)? It results in abduction and upward movement of the arms followed by adduction and flexion. A. Moro reflex B. Root reflex C. Jones reflex D. Babinski reflex

A. Moro reflex

What condition is associated with wearing ill-fitting, high heeled, or pointed-toes shoes? A. Morton's neuroma B. Plantar fasciitis C. Cauda equina syndrome D. Hallus rigidus

A. Morton's neuroma

What is the frequent cause of exercise induced patellar pain and swelling at the tibial tubercle in pre-adolescent girls and early adolescent boys? A. Osgood-Schlatter disease B. Charcot-Marie-Tooth disease C. Baker's cyst D. Osteochondritis dissecans

A. Osgood-Schlatter disease Explanation: Osgood-Schlatter disease refers to a microfracture at the ossification center near the tibial tubercle, where the patellar tendon inserts. (B) Charcot-Marie-Tooth disease is characterized by cavus foot, and familial neuropathy. (C) Baker's cyst results from stretching of the gastrocnemius and semimembranosus bursa. It is usually painless during childhood. (D) Osteochondritis dissecans results from a vascular insult to the articular cartilage at the knee, most commonly at the lateral aspect of the medial femoral condyle.

A 54 yo female with BMI of 32 and a past medical history of lumbar fusion 1 year ago for lumbar stenosis presents with medial knee pain. The pain began 4 weeks ago, but she denies any trauma. The area hurts to touch, and she feels like it is intermittently swollen. On exam, her maximal area of tenderness to palpitation is 2-3 cm inferior to the mid-medial joint line. She has no effusion, her McMurry test is negative, and her ligaments are intact. What is the most likely diagnosis? A. Pes anserine bursitis B. Meniscal tear C. Gout D. Septic arthritis

A. Pes anserine bursitis Explanation: Pes anserine bursitis is a common pathology that often is mistaken as osteoarthritis or meniscal tear. This is an important diagnosis not to miss because the treatment may be only topical anti-inflammatories, rather than systemic anti-inflammatory medications. In addition, the treatment should involve therapy that improves gait and hip strength, since often the etiology involves abnormal forces on the knee because of pelvic weakness. Her history of back problems could have led to gait changes and hip muscle weakness, which may be the source of her knee pain. (B) There is no effusion on exam, and McMurray test is negative. There is no history of specific injury. Meniscal tears can occur insidiously and may not have a large effusion, but they usually show some joint fluid. In addition, the exam (C) Gout would cause red, hot, swollen knee joint, and she does not have this on exam. (D) A septic joint would likely present as a red, hot, and swollen knee joint.

An 11 yo boy was tackled while playing football and landed on his shoulder. He immediately complained of upper chest pain and dyspnea. On exam, he has mild neck-vein engorgement and a swollen sternoclavicular joint. What is his most likely diagnosis? A. Posterior sternoclavicular joint dislocation B. Clavicle fracture C. Cervical strain D. Rib fracture

A. Posterior sternoclavicular joint dislocation Explanation: Posterior sternoclavicular joint dislocations are rarer than anterior sternoclavicular dislocations but are a life-threatening emergency when they do occur. Open or closed reduction should occur as soon as possible while the patient is monitored and under controlled conditions in the presence of a cardiothoracic surgeon. Patients with SC injury usually have anterior chest and shoulder pain that is worsened with arm movement. Patients with SC dislocation may also c/o difficulty breathing, dysphagia, or upper extremity paresthesia. If posterior displacement of the medial clavicle or clavicular fracture injuries the recurrent laryngeal nerve, hoarseness may also be present. Displacement may be difficult to appreciate. (B) clavicle fracture is less likely than posterior SC joint location. Clavicle fracture involves pain on palpitation and typically deformity of the clavicle. (C) Cervical strain presents as neck pain, often after an acute injury like whiplash during a motor vehicle accident. A strain can sometimes cause paresthesia if there is a muscle spasm that irritates a nerve running through it. It is not associated with symptoms in case above. (D) Rib fracture will cause pain with respiration but is unlikely to cause the symptoms listed above. The mechanism of injury also makes it less likely.

A 30 yo male presents after sustaining a right-knee injury 2 days ago. He was playing basketball when he injured his knee by landing from a jump. He was able to walk off the court but has some swelling since. His knee does not hurt, but he as a decreased range of motion. He does not feel unstable and denies any clicking or grinding. He has no previous injury or surgery. On exam he has some mild swelling but no deformity. There is no pain on palpation except at the medial joint line. His range of motion is normal in flexion but extension is limited to +10 degrees. He has a negative Lachman's test. X-rays ordered in the office are normal. What is the next step? A. Refer to surgery for arthroscopic treatment B. Perform arthrocentesis followed by steroid injection C. Refer to physical therapy D. Prescribe rest, NSAIDs, and knee brace.

A. Refer to surgery for arthroscopic treatment Explanation: Knee extension is normally between 0 and -10 degrees. The patient's injury is characterized by lack of full extension (locked knee), pain over the medial joint line, and effusion. This is concerning for a "bucket-handle" meniscal tear. This a relative surgical emergency and should be addressed within a few days. "Locking" may occur in meniscal tears as a result of the torn flap, the "bucket-handle," impinging between the articular surfaces.

A 50 yo Caucasian female presents to office with morning joint stiffness mostly in her feet and hands that last up to 2 hours after starting her day. She reports this happened about a month ago and her wrist were very sore, but she seemed to get better. She also reports feeling tired lately, her cloths are looser, and sometimes she thinks she may have been running a fever. Exam reveals swelling and warmth in the MCPs and PIPs of both hands. Based on history, exam, and symptoms what is the most likely diagnosis? A. Rheumatoid arthritis B. Osteoarthritis C. Systemic lupus erythematous D. Carpal tunnel

A. Rheumatoid arthritis Explanation: These are classic symptoms of RA which include systemic symptoms and symmetric inflammation of MCP and PIP of the hands (may have sausage digits). Other commonly affected joints are the wrist, metatarsophalangeal joints of the feet, ankles, elbows, and shoulders. RA is associated with relapsing and remitting symptoms. Articular symptoms may pe associated with systemic symptoms such as weight loss, weakness, fatigue, decreased appetite, and aching. RA affects females more than males and tends to present in the middle age. Joint stiffness last longer than OA. (B) OA does not present with systematic symptoms, does not have symmetrical distribution and generally presents without inflammation. OA tends to affect the hips, knees, DIPs and PIPs. Symptoms are exacerbated by activity and relieved by rest. (C) SLE is associated with relapsing and remitting symptoms. However, it tends to present in women of childbearing age and presents with anorexia, seizures, oral ulcers, fatigue, rash, and arthritis ) of two or more peripheral joints). (D) carpal tunnel is associated with joint pain as well as numbness, tingling, weakness due to impingement of the median nerve. Symptoms often resents as wrist pain with numbness, and tingling of the thumb, index, middle, and ring finger. May also notice marked weakness, inability to grip objects, and nighttime numbness. Tow important test are Tinel's sign and Phalen test. Risk factors include repetitive movements and overuse.

A 15 yo competitive swimmer presents with pain in the right shoulder aggravated by movement. Exam is significant for tenderness on palpitation and muscle weakness in the affected arm. Physical fractures and apophysitis have been ruled out. What is the most likely diagnosis? A. Rotator cuff tendinopathy B. Sprengel deformity C. Spondylolysis D. Spondylolisthesis

A. Rotator cuff tendinopathy Explanation: Rotator cuff tendinopathy is an overuse injury commonly found in swimmers. Therapy includes ice, anti-inflammatories, activity modification, and physical therapy. (B) Sprengel deformity refers to congenital elevation of the scapula, which can be associated with webbed neck, low posterior hairline, and Klippel-Feil syndrome. (C) Spondylolysis refers to abnormalities of he pars interarticularis of the vertebrae. (D) Spondylolisthesis is defined as slippage of the superior over the inferior vertebrae. This occurs more commonly in adolescents in participating in sports requiring frequent back extension (gymnastics and diving)

A 19 yo male basketball player had a sudden onset of dyspnea and chest pain during practice. There was no specific preceding traumatic injury, he has no personal or family history of clotting disorders, and he has not been on a long car or plan trip. In the ER, his temp was 98.6, HR 120, BP 120/80, RR 20, and O2 94% RA. The patient's HT is 6'11, WT 190 lbs, and BMI 19.4. He does not have detected breath sounds in his left lower posterior lobe auscultation area. What is the most likely diagnosis? A. Spontaneous pneumothorax B. Pulmonary Embolus C. Rib Contusion D. Myocardial ischemia

A. Spontaneous pneumothorax Explanation: The basketball player's gender and habitus intrinsically places him at risk for pneumothorax (mall and tall). His VS and exam suggest this probable diagnosis. He may be at risk for recurrent episodes with his habitus. (B) While pulmonary embolus is also possible, with his habitus and exam findings, it is lower on the differential list than a spontaneous pneumothorax. (C) While basketball is a contact sport, only sizable force or collision can cause a rib contusion.

A 15 yo with no PMH presents with shoulder pain that has occurred for several years. He has been playing baseball since he was 10, and the shoulder pain has increased gradually. He denies any trauma but does not state after he pitches, he feels a sensation of coldness in his hand along with tingling and burning of the arm and forearm. Pain has occurred for many years, but it has worsened since he started playing baseball. Pain is relieved with NSAIDs and it is not related to temperature or time of day. VS WNL. Exam shows decreased coloring of the hand and difficulty moving the shoulder in any direction. There is no pinpoint tenderness identified. What is the most likely diagnosis? A. Thoracic outlet syndrome B. Rotator cuff tendonitis C. Shoulder impingement D. Proximal humerus stress injury(Little Leaguer's shoulder)

A. Thoracic outlet syndrome Explanation: Thoracic outlet syndrome occurs when there is compression at the superior thoracic outlet resulting from excess pressure placed on a neurovascular bundle between the scalene muscles. Because the nerves of the upper limb and or vessels pass through the outlet, all of them can be affected. Typically, the syndrome is caused by congenital abnormalities such as a cervical rib or prolonged transverse process, or by trauma or repetitive strain. Patients present with sharp, burning pain of the upper arm, forearm, and/or fingers. Decreased coloring of the hands, tingling, and coldness are commonly found. Our patient's shoulder, arm, and hand pain probably began with a congenital anomaly at birth that has worsened with repetitive trauma from baseball. The tingling, burning pain in his arms and fingers along with discoloration make this answer the best choice.

Which of the following is the most appropriate way to diagnosis scoliosis? A. Upright PA and lateral films B. Supine AP and lateral C. AP lateral, flexion, and extension D. AP, lateral, and sunrise

A. Upright PA and lateral films Explanation: Scoliosis is a common diagnosis in the pediatric population. Most individuals do not require bracing or surgery. Management is determined by pain and severity of angulation, which is first assessed by plain films. PA films allow less radiation than AP films

A high school student plays tennis and basketball most days. He presents with his mother complaining of a ball-like mass behind his right knee. He is in otherwise good health and denies any acute trauma. Exam reveals normal vital signs. The patient has a soft, smooth mass that is tender to palpation, located behind the knee. There is no overlying redness or warmth. Which of the following is indicated? A. MRI B. RICE C. Joint aspiration for culture and sensitivity D. Refer to orthopedics

B. RICE Explanation: the patient presents with Baker's cyst. A Baker's cyst, or popliteal cyst, is a type of bursitis that results from swelling and inflammation behind the knee from joint damage, usually over a long period of time. The bursa, a protective synovial sac in the posterior potion of the joint, can rupture, which may result in increased inflammation and may resemble cellulitis over the surround area, including the posterior calf. First line treatment is RICE with NSAIDs as needed. If the bursa is large, draining with an 18-guage syringe can relieve discomfort. The synovial fluid should be a clear golden color. If the fluid is cloudy or bloody, order a C&S to rule out septic joint infection.

A 17 yo football player with no PMH suffered an inverted ankle sprain 20 hours ago when playing football. During the game, he intercepted the ball and landed on an opponent's foot. He rolled his ankle over his opponent's foot and complained of extreme pain and tenderness immediately. He was carried off the field by teammates and was taken home to ice and wrap the ankle. Earlier this am his ankle became very swollen, and he has not been able to put any weight on it. There is tenderness to palpation at the lateral malleolus, but not at the medial malleolus or the metatarsals. He does not complain of any numbness or tingling. VS are normal. Exam reveals tenderness and swelling over the entire ankle region and pain upon inversion, eversion, and plantar flexion and dorsiflexion. There is tenderness to palpation to the lateral malleolus. There is no deformity or crepitus. Examination of the ligaments is significant for a completely torn structure. What is the next step in management? A. Foot x-ray series B. Ankle x-ray series C. Cryotherapy D. Conservative management (RICE, NSAIDs, walking boot)

B. Ankle x-ray series Explanation: A grade III ankle sprain, which the ligament is completely torn. Grade II describes a partially torn ligament, while Grade 1 involves only a stretched ligament. Patients have severe pain, swelling, tenderness, and ecchymosis. There is significant mechanical instability on exam and sometime a loss of function and motion. Patients are unable to bear weight or ambulate. Tenderness at either of the malleoli or inability to bear weight is a requisite for performing an ankle x-ray series to check for structural damage to the ankle.

In evaluation of polyneuropathy, which study would not be recommended? A. Sedimentation rate (ESR) B. Basic metabolic panel (BMP C. Hemoglobin A1c (HbA1c) D. Electromyography (EMG)

B. Basic metabolic panel (BMP) Explanation: It is not necessary to obtain a BMP. (A) Many toxins and inflammatory processes are involved with polyneuropathy, therefore, the sedimentation rate would be highly useful. (C) The hemoglobin A1c (HgbA1c) would be ordered to evaluate the relative control of diabetes. Diabetes is a common cause of peripheral neuropathies. (D) Electromyography (EMG) is often performed to evaluate both nerve conduction and needle electrode examination.

A 62 yo female presents with c/o sudden onset of difficulty walking. She has been in good health, although she was recently treated with a course of antibiotics for traveler's diarrhea. On exam she has a positive Thompson test and ultrasound confirms Achilles tendon rupture. Which of the following drugs was most likely prescribed from the patient's GI complaint? A. Bactrim B. Cipro C. Macrobid D. Amoxicillin

B. Cipro Explanation: Cipro is a fluoroquinolone. Achilles tendon rupture is a serous complication of quinolone therapy. There is a 3-4 fold increase risk of tendon rupture with use of quinolones, usually the Achilles tendon. Patients at highest risk are typically older than 60 years or on steroids. Patients who develop difficulty walking should undergo ultrasound evaluation of the tendon and the medication should be stopped. Quinolones are also contraindicated in pregnant women, breast-feeding mothers, and in pediatric patients due to effects on growing cartilage. they are also contraindicated in patients with myasthenia gravis.

A patient is examined for a complain of wrist pain after falling out on his outstretched hand. On exam, the patient c/o tenderness with palpation over the anatomic snuffbox. There is no obvious deformity and x-rays of the wrist are normal. Which of the following diagnosis should be suspected? A. De Quervain's tenosynovitis B. Colles fracture C. Scaphoid fracture D. Wrist sprain

B. Colles fracture Explanation: Classic presentation is a patient with a history of a fall on an outstretched hand who demonstrates tenderness over the anatomic snuffbox and pain with axial loading of the thumb. X-rays may be normal, but repeat

An 11 yo male was playing baseball as a pitcher when he took a line drive to the chest. He immediately collapsed on the field and was unresponsive. What is his most likely diagnosis? A. Mediastinal carcinoma B. Commotio cordis C. Rib fracture D. Pulmonary contusion

B. Commotio cordis Explanation: Commotio cordis is a cause of sudden cardiac death in sports. Common sports are baseball, lacrosse, and hockey. Softer balls have been attempted in baseball, and rule changes are also thought to decrease risk, but evidence has not yet shown this to be true. (D) Pulmonary contusion is possible but less likely to lead to immediate collapse.

A 17 yo football player with no PMH suffered an inverted ankle sprain 20 hours ago when playing football. During the game, he intercepted the ball and landed on an opponent's foot. He rolled his ankle over his opponent's foot and complained of extreme pain and tenderness immediately. He was carried off the field by teammates and was taken home to ice and wrap the ankle. Earlier this am his ankle became very swollen. Which of the following is not one of the Ottawa criteria that indicated when x-ray imaging is needed? A. Tenderness of medial malleolus B. Tenderness of lateral malleolus C. Tenderness of cuboid bone D. Tenderness of 5th metatarsal.

C. Tenderness of the cuboid bone Explanation: (A) (B) if the patient cannot bear weight or has tenderness in either malleoli, and x-ray series of the ankle is needed. (D) if the patient has tenderness of the navicular bone or 5th metatarsal, an x-ray series of the foot is needed.

A 33 yo female with PMH of DM c/o of pain in her wrist. The pain is located along the radial side of the wrist and has been occurring for a long time. She feels a reduced sensation along the radial side of her hand with occasional numbness and tingling. In addition, she also feels an occasional temperature change in her hand that she describes as a "cool feeling." She does not know exactly when the pain started and cannot recall any trauma or injury to the site. V/S are normal. Exam reveals a well-circumscribed, subcutaneous, soft, mobile wrist mass that is non-tender to palpitation and transilluminates with lighting. The patient has trouble gripping objects. What is the most likely diagnosis? A. Lipoma B. Ganglion cyst C. Radial artery aneurysm D. Osteosarcoma

B. Ganglion cyst Explanation: A ganglion cyst is a cystic swelling typically found on the dorsal side of the wrist. These cyst are thought to arise from herniation of synovial tissue from a joint capsule or tendon sheath. They present with chronic wrist pain and may be accompanied by coolness of the hand, numbness/tingling, and possible parethesias. The mass itself is mobile, may be tender to palpation, and transilluminates. (A) Limpoma is a benign tumor of fat that can occur on the hand. Lipomas are soft to the touch and mobile. Unlike Ganglion cyst, lipomas typically do not cause hand symptoms and are not well circumscribed. They do not transilluminate either. (C) Radial artery aneurysms are dilations of the radial artery that extend into the hand. While there is no history of trauma, they present as pulsatile masses without any pain and do not transilluminate either. (D) Osteosarcoma are cancerous tumors occurring in the bone. While they occur typically on the shoulders, elbows, and knees, they can occur in the hand as well. Unlike ganglion cyst, they are not well-circumscribed and are fixed rather than mobile.

A 68 yo male presents with an acute onset of a red, swollen, painful knee. He has diabetes, hyperlipidemia, and chronic kidney disease. He denies fevers, chills, and trauma. HIs VS are Temp 98, HR 70, BP 140/80, RR 14. On exam, he has a joint effusion with erythema and generalized tenderness. There is no streaking. Fluid from the knee aspiration reveals a cell count of >1000, and his culture 72 hours later shows no growth. What is the most likely diagnosis? A. Prepatellar bursitis B. Gout C. Septic arthritis D. Meniscal tear

B. Gout Explanation: The sudden onset and comorbidities are highly suspicious for gout. The white blood cell count is not high enough to suggest a bacterial joint infection, but it does suggest an inflammatory process. Of the answers given, gout is the most likely diagnosis. The joint aspirate in a patent with acute gout also contains negatively birefringent needle shaped crystals of monosodium urate. (A) Prepatellar bursitis can be difficult to distinguish from other diagnoses, as it causes redness and swelling in the knee area. As the bursa is extra-articular, it does not cause knee effusion. (C) Gout and septic arthritis can present similar clinically. The best management is to aspirate the knee to obtain a cell count. While joint-filled aspiration only grows a specific organism <50% of the time, his cell count makes septic joint unlikely. Bacterial joint infections usually produce purulent effusion with leukocyte counts (most of which are neutrophils) of 50,000 to 150,000 cells/mm3. (D) Meniscal tears can be insidious in this age population and can cause joint effusions. However, they are unlikely to cause erythema.

What are the most common location of osteochondritis dessicans (OCD) lesions in pediatric patients? A. Cervical, thoracic, and lumbar spine B. Knee, ankle, and elbow C. Pelvis, toe, and nasal plate D. Eye, ear, and palate

B. Knee, ankle, and elbow

A 42 yo male who plays basketball on the weekends has medial knee pain after landing on the extremity and pivoting sideways to pass. He felt a "pop" and experienced swelling a few minutes later. He has pain with walking. He denies any instability but does feel like it is "catching" with knee flexion. On exam, he has joint effusion, his Lachman's is negative, and he has no pain with patella mobility. What is his most likely injury? A. Anterior cruciate ligament B. Meniscal injury C. Tibial plateau fracture D. Osgood-Schlatter disease

B. Meniscal injury

An 83 yo male presents with c/o left knee pain with intermittent swelling that last a few days and then self-resolves. He denies any recent trauma. He has a past medical history of knee arthroscopy (knee scope) when he was 50 along with removal of a part of the meniscus. Otherwise, he only has well-controlled hypertension. Exam has a small joint effusion with no erythema and mild pain to palpation along his medial joint line. There is no erythema or streaking. What is the most appropriate step in management of his problem? A. Obtain supine x-rays B. Obtain standing bilateral x-rays C. Obtain sunrise view bilateral x-rays D. Obtain MRi

B. Obtain standing bilateral x-rays. Explanation: Standing bilateral x-ray allows evaluation of the amount of joint space a patient has. Weight bearing plain films are necessary to do this and supine films will not be helpful. Bilateral films are necessary to do this, and supine films will not be helpful. Bilateral films allows for comparison to the contralateral side. (A) Supine x-rays do not allow for true assessment of the joint space. These can be used for traumatic injury when a patient cannot bear weight. (C) Sunrise view assess the patellofemoral joint. An individual this age likely as some osteoarthritis in this joint as well, but because it is not continuous with the knee joint, it would not be responsible for the effusion.

A 23 yo health scuba driver with no medications begins to have retrosternal chest pain 4 hours after her ascent to the surface. She has never had any problems related to diving before. She was well within her prescribed dive times and followed appropriate guidelines in her ascent. On exam, she appears anxious and has palpable swelling in her neck. A crunching sound is heard over the precordium during the cardiac exam. What is the most likely diagnosis? A. Commotio cordis B. Pneumomediastinum C. Pulmonary barotrauma D. Pulmonary embolus

B. Pneumomediastinum Explanation: Pneumomediastinum most often occurs in scuba divers or with trauma in sporting events. Free air in the mediastinum can be observed on x-ray. Crepitus, as with this patient, if often found on physical exam, as well as Hamman's sign )rales over the precordium). Treatment is supportive care while air resorbs. If there are any diagnostic questions a CT is the image of choice. (A) is caused by a direct blow to the chest. In porcine studies, it has been found that the blow likely needs to occur at a certain time of a heartbeat to cause commotion cordis. (C) Pulmonary barotrauma is caused when a SCUBA diver holds his or her breath during the ascent to the surface. The compressed gas expands during the ascent. Symptoms will typically begin immediately upon ascent. (D) Pulmonary embolus can cause chest pain but is unlikely to cause crepitus on exam.

Which of the following has not been shown to lower the risk of osteoporosis? A. Vitamin D supplement B. Weight-bearing exercises C. Consuming organic juice D. Consuming low-fat dairy

C. consuming organic juice

A 65 yo female presents with bilateral morning stiffness and aching that usually last up to an hour, primary in her shoulders, neck, and hips. Her erythrocyte sedimentation rate is elevated. The NP diagnoses the patient with polymyalgia rheumatica. Which of the following is true? A. She is at risk for aortic aneurysm B. She is at risk for temporal arteritis C. Symptoms are unresponsive to steroids D. symptoms should be treated with Humira

B. She is at risk for temporal arteritis Explanation: Polymyalgia rheumatica is a common inflammatory condition that affects the elderly. Its etiology is unknown. It is characterized by proximal hip and shoulder stiffness lasting longer than 30 minutes in the morning. PMR is a clinical diagnosis and responds well to oral steroids. Females older than 50 years of age are affected most commonly. PMR is associated with a high risk of developing temporal arteritis, so all PMR patient should be instructed on the signs of temporal arteritis. If a patient with PMR presents with signs of temporal arteritis begin high-dose steroids as soon as possible and bean treatment in the office if the patient is unable to or unwilling to see an ophthalmologist. Both ESR and CRP are elevated in temporal arteritis in which ophthalmologic emergency. 15 to 20% of patients become blind.

A 14 yo female soccer player felt a pop in her knee while running. She has immediate pain and swelling in the knee and cannot bear weight. She feels unstable while walking. ON exam on the sideline, she has an overt effusion and tenderness along the tibial plateau. What orthopedic exam test would be helpful in making a diagnosis? A. McMurray's test B. Stork test C. Lachman's test D. Tinel's test

C. Lachman's test Explanation: Exam and history are most likely an anterior cruciate ligament (ACL) tear. Lachman's test assess the integrity of the ACL. IN this test, the femur is held steadily while the tibia is moved anteriorly. A firm end-point and symmetry of anterior translation as compared to the contralateral side indicates low likelihood of an ACL tear. (A) McMurray's test assess meniscal injury. Knee pain with external and internal movement of the tibia (to compress the meniscus between the femur and tibia) indicates a positive test and raises concern for a tear. (B) the assessment of the Stork test is a test of mobility of the sacroiliac joint and involves palpitation of the posterior superior iliac spine (PSIS). (D) A positive Tinel's test involves paresthesia in the median nerve distribution with tapping the area of the median nerve. A positive test raises concern for carpal tunnel syndrome.

Which of the following patients is most likely to have osteoporosis? A. 33 yo female who smokes 1 pack of cigarettes per day B. 46 yo male with a history of asthma treated with steroids 1-2 times per year C. 52 yo female with history of ulcerative colitis D. 26 yo male with history of alcohol abuse

C. 52 yo female with history of ulcerative colitis Explanation: Inflammatory bowel disease is a significant risk factor for osteoporosis. Both ulcerative colitis and Crohn's disease have a high association (up to 40%) with low bone bass. Smoking, heavy alcohol use, chronic steroid use, and advanced age are additional risk factors for osteoporosis.

Which of the following patients would be a candidate for bisphosphonate therapy? A. 55 yo female who sustained an open-book pelvic fracture after high speed MVA B. 36 yo female who broke her arm playing softball C. 60 yo female with a recent hip fracture after a fall from standing. D. 80 yo male who is non-ambulatory

C. 60 yo female with a recent hip fracture after a fall from standing. Explanation: Treatment with bisphosphonate therapy is recommended for post-menopausal women who have had a low impact fracture or who have established osteoporosis based on bone mineral density testing. Recommendations are similar for men over the age of 50 or pre menopausal females who have low bone mass. A fracture which results from a high impact mechanism does not qualify a patient as a candidate for bisphosphonate therapy.

A 25 yo male patient limps in to the clinic for right knee pain. He reports that joint became painful and swollen after playing soccer two days ago. He has been taking ibuprofen for pain and trying to stay of knee, but pain and swelling persist. You perform the following orthopedic maneuvers with these results. Anterior drawer sign-positive McMurry test - negative Lachman test- Positive Balloon sign - Positive A. Medial meniscus tear B. Fractured patella C. ACL tear D. Osteoarthritis

C. ACL tear

The NP places a client in the prone position with the knee flexed to 90 degrees. The tibia is firmly opposed to the femur by exerting downward pressure on the foot. The leg is rotated externally and internally. If locking of the knee occurs, this is accurately called a positive: A. Drawer sign B. McMurry test C. Apley sign D. Bulge sign

C. Apley's sign Explanation: The Apley's sign, locking of the knee or the sounds of clicks and pain, may indicate a loose body, such as a torn cartilage. (A) the Drawer sign tests the cruciate ligament with the client in sitting and lying positions, not prone. (B) The McMurry's test is used to detect a medial meniscus injury. In this test the knee is fully flexed and the tibia is externally rotated. (D) Varus pressure is applied to the knee while it is extended. For detection of a medial meniscus tear, the test is allied to the knee.

A 38 yo tennis player with PMH of HTN c/o pain in the left wrist. The pain is located along the dorsal radial side of the wrist and has been occurring for several months. She feels a reduced sensation along the radial side of her hand with accompanying numbness and tingling. In addition, she feels an occasional temperature change in her hand that she describes as a "cooling feeling." She does not know exactly when the pain and discomfort started and cannot recall any traumatic or inciting event. VS are normal. Exam reveals a subcutaneous, mobile wrist mass that is non-tender to palpitation and transilluminates with lighting. Patient has trouble gripping objects. What is the most likely diagnosis? A. Fracture of scaphoid bone B. DeQuervain's tenosynovitis C. Ganglion cyst D. Carpal tunnel syndrome

C. Ganglion cyst Explanation: (A) the scaphoid bone is the most fractured bone in the wrist, and this injury typically occurs in young to middle-aged men who fall on an outstretched hand. Our patient has not history of trauma or falling. (B) DeQuervain's tenosynovitis is the entrapment of the abductor pollicis longus and extensor pollicis brevis tendons at the styloid process of the radius. It is the most often cumulative movement disorder due to chronic overuse of the wrist and hand. DeQuervain's typically occurs in women between the ages of 30-50, and it presents with tenderness over the radial aspect of the wrist that may radiate up to the tip of the thumb. There may or may not be erythema, but crepitus is rarely noted. There is a link between this disease and pregnancy and in patients who do physical activities that requires repetitive hand motions. (D) Carpal tunnel syndrome is compression of the median nerve traveling through the flexor retinaculum.

A NP is examining the hands of her 67 yo female patient and she notes bony nodules located at the distal interphalangeal joints in both hands. Which of the following is most likely? A. Bouchard's nodes B. Swan neck deformity C. Heberden's nodes D. Tophi

C. Heberden's nodes Explanation: Bony nodes that develop at the distal interphalangeal joints in patients with osteoarthritis. (A) Bouchard's nodes develop at the proximal interphalangeal joints. (B) Swan's neck deformity is caused by hyperextension of the PIP joint and hyperflexion of the DIP joint, usually seen with RA. (D) Tophi are associated with gout, caused by high levels of uric acid, which can precipitate in the joints and form nodules.

A 33 yo woman with a history of DM c/o mild pain in her wrist. The pain is located along the radial side of the wrist and has been occurring for a long time. She reports reduced sensation along the radial side of her hand with accompanying numbness and tingling. In addition, she notes an occasional temperature change in her hand that she describes as a "cool feeling." She does not know exactly when the pain and discomfort started and cannot recall any traumatic or inciting event. VS or normal. Exam reveals a well-circumscribed, subcutaneous, soft, mobile wrist mass that is non-tender to palpation and transilluminates with lighting. She has taken pain medication with no improvement in her symptoms. Which of the following diagnostic test is indicated for this patient? A. X-ray B. Ultrasound C. MRI D. Arthroscopic exam E. No imaging needed

C. MRI Explanation: A ganglion cyst is a cystic swelling typically found on the dorsal side of the wrist. These cyst are thought to arise from herniation of synovial tissue from a joint capsule or tendon sheath. Most cyst are diagnosed by history and exam with no imaging needed. However, this patient presents with pain and neurovascular symptoms, indicating possible structural damage of the cyst invading deeper tissues. In these cases MRI will allow the best visualization of the tissue and assess neurovascular damage more accurately.

A 52 yo female presents to your clinic with 2 month history of intermittent pain in her wrist and forearm on both side, in addition to numbness and tingling in the thumb and index fingers with prolonged use. The patient has positive Tinel's sign, pain shooting from the wrist to the hand. On performing Phalen's test, instructing the patient to bed the wrist forward completely for 60 seconds, numbness, tingling, and weakness are reproduced. The phalen test is used to assess: A. Osteoarthritis B. Tenosynovitis C. Median nerve inflammation D. Medial cruciate ligament

C. Median nerve inflammation Explanation: Carpal tunnel syndrome

Treatment for gouty arthritis during an acute attack is: A. ASA B. Probenecid C. Naproxen (Naprosyn) D. Allopurinol (Zyloprim)

C. Naproxen (Naprosyn) Explanation: (A) ASA is not recommended as a first line of treatment for gout. (B) Probenecid helps to increase they body's excretion of uric acid. It is used for chronic gout to prevent attacks, but not during an attack. (D) Allopurinol is the first line for chronic gout and prevention of gouty attacks; however, it is not used to treat gouty attack and it is unclear whether or not it can make attacks worse. Allopurinol can be started four to six weeks after an attack.

The nurse practitioner understands that chronic synovitis with pannus formation is the basic pathophysiologic finding in clients with: A. Systemic lupus erythematosus (SLE) B. Ankylosing spondylitis (AS) C. RA D. Osteoarthritis

C. RA Explanation: The chronic inflammatory disorder of RA is associated with synovial hypertrophy from chronic synovitis and pannus formation that results in progressive destruction of cartilage. (A) SLE has a distribution of symptoms similar to that of RA but no pannus formation. (B) AS usually involves the large peripheral joints and is characterized by extreme kyphosis. (D) There is no inflammation with osteoarthritis.

A nurse practitioner in a family practice clinic is evaluating a patient with an ankle injury. The patient is an otherwise healthy 20 yo male who hurt his ankle during a soccer game. He is able to bear weight and ambulate. Which of the following is indicated? A. Referral to orthopedics B. X-ray ankle C. RICE D. Cast and non-weight bearing

C. RICE Explanation: Ankle injuries are common. The Ottawa ankle rules are used to determine whether or not the patient needs radiographies of the injured ankle. A grade I sprain, which is mild and characterized by slight stretching and minimal damage to the ligamentous fibers, can be treated with RICE. These patient will be ale to bear weight and ambulate. A Grade II sprain refers to partial tearing of the ligament, characterized by the presence of moderate swelling and pain, ecchymosis, and joint tenderness to palpitation. Patients will c/o pain with ambulation and weight-bearing. There will be mild instability of the joint. For these patients consider an X-ray and referral to orthopedics. Complete rupture of the ligaments of the ankle characterized a Grade III sprain. These sprains would be referred to the ED. Patients may have a fracture. They will be unable to bear weight immediately after the injury, with inability to bear weight immediately after the injury, with inability to ambulate at least 4 steps. Tenderness is present over the posterior edge of the lateral or medial malleolus. There may also be serve pain with bruising and swelling.

A 15 yo male with no PMH presents with shoulder pain that occurred for more than 4 months. He has been a baseball pitcher for most of his life, and he started feeling tenderness around his shoulder region 4 months ago. He denies any trauma but does state that several months ago, he felt a pull on his shoulder when the threw a fast ball, resulting in pain after the incident. The pain has not progressed since the incident and has improved with lidocaine injection. The pain is not related to temperature but tends to worsen during the evening. VS are normal. Exam shows tremendous difficulty in lifting his left arm above his head accompanied by pain. What is the most likely diagnosis? A. Thoracic outlet syndrome B. Rotator cuff tendonitis C. Shoulder impingement D. Proximal humerus stress injury (Little Leaguer's shoulder)

C. Shoulder impingement Explanation: Shoulder impingement is a clinical syndrome that occurs when the tendons of the rotator cuff become irritated and inflamed as they pass through the subacromial space. It presents with pain, weakness, and decreased ROM in the shoulder. Pain is often exacerbated by shoulder movement, especially when lifting the arm over the head. Onset of the pain may be acute or chronic, and it can be accompanied by grinding sensation during shoulder movement. Typically, pain in impingement is not related to temperatures, worsens in the evening, and improves with lidocaine injection. (A) Thoracic outlet syndrome occurs when there is compression at the superior thoracic outlet resulting from excess pressure placed on a neurovascular bundle between the scalene muscles. Because the nerves of the upper limp and/or vessels pass through the outlet, all of them can be affected. Typically, the syndrome is caused by congenital abnormalities such as cervical rig or prolonged transverse process, or by trauma or repetitive strain. Patients present with sharp, burning n the upper arm, forearm, and /or fingers. Decreased coloring of the hands and coldness re commonly found in addition to tingling. Our patient lacks the sharp burning symptoms and tingling required for diagnosis. (B) Rotator cuff tendinitis is the swelling of the rotator cuff tendons from repetitive activities associated with overuse of the arm and shoulder, especially in physical activities such as volleyball or baseball. Symptoms involve shoulder weakness and difficulty lifting the arm over the head. In addition, there may be pain and swelling in the front of the shoulder, a clicking sound when the arm is raised, and stiffness. Resting the shoulder and icing it along with ibuprofen treatment should improve the symptoms. (D) Proximal humerus stress injury is an injury to the growth plate of the proximal humerus as a result of repetitive microtrauma found in young pitchers who throw many breaking balls. Patients present with arm and shoulder pain when throwing the all that increases in intensity over time. Pain is worsened in the late cocking or deceleration phases of throwing and resolves with rest.

A 20 yo female soccer player was chasing another player and felt a pop in her left knee as she was cutting. She had significant swelling and difficulty bearing weight on her left leg, believing that her knee was going to give out. VS are normal. BMI is 28. Exam reveals tenderness over the anterior knee portion and swelling all around the knee. You suspect an ACL tear and want to perform an examination to assess knee damage. Which of the following test is considered the be the least helpful in diagnosing an acute ACL tear of the knee? A. Lachman test B. Pivot-shift test C. MRI of the knee D. Anterior drawer test

D. Anterior drawer test Explanation: This test involves the patient lying supine with hips flexed to 45 degrees: the knee is flexed to 90 degrees, and the feet are flat on the table. The examiner grasp the tibia just below the joint line of the knee. The thumbs are placed along the joint line on either side of the patellar tendon. Then the tibia is drawn forward anteriorly. If the tibia pulls forward more than normal, the test is considered positive for ACL tear. This test has the lowest possible predictive value (PPV) of all of the ACL test at 29%. The anterior drawer has good sensitivity and specificity in chronic conditions (both.90%), but it is typically accurate in acute injury.

A 14 yo football player returns 1 week after being diagnosed with mononucleosis by Monospot test and 2 weeks after his symptoms began. VS normal. What is the next step in management? A. Obtain abdominal ultrasound 1x per week for 4 weeks to assess spleen size. B. Obtain repeat Monospot test and EBV serology. C. Obtain weekly liver-function test and perform weekly abdominal exams. D. Advise avoidance of football for 3- week minimum from start of symptoms. Patient may return to activity when all symptoms have resolved.

D. Advise avoidance of football for 3-week minimum from start of symptoms. Patient may return to activity when all symptoms have resolved. Explanation: Mononucleosis is a common diagnosis in the adolescent population. While recommendations that do exist identify 3 weeks from initial of symptoms minimum to refrain from contact sports because of the risk of splenic rupture. Once 3 weeks have passed and the athlete is afebrile, has resumed appropriate nutritional intake, and is a normal energy levels. resumption of participation can be discussed.

Gymnast's wrist is associated with which of the following conditions? A. Osteochondritis dissecans of capitellum B. Apophyseal avulsion fracture of the humeral epicondyle C. Subluxation of the radial head D. Injury to the distal radial physis

D. Injury to the distal radial physis Explanation: A gymnast wrist refers to injury to the distal radial physis, occurring as a result of repetitive stresses due to weight bearing on the upper extremities. (A) (B) Osteochondritis dissecans of the capitellum and apophyseal avulsion fracture of the medial humeral epicondyle are associated with Leaguer's elbow. (C) Subluxation of the radial head is associated with nursemaids elbow.

What is the following is NOT a common fracture site associated with osteoporosis? A. Hip B. Forearm C. Spine D. Lower leg

D. Lower leg Explanation: Osteoporosis causes bone fragility and leads to increased fracture risk. The most common sites of fracture associated with osteoporosis are the hip, forearm, humerus, spine, and pelvis. Fracture of the lower leg is not clearly associated with osteoporosis.

A 19 yo woman presents to your clinic for pain in her feet for the past several days. She denies trauma but recently started getting back into ballet dancing. She says it really hurts when she starts to walk or jump. She denies any rash or other complaint. Her vitals are as follows: BP 90/60, HR 60, RR 14, Temp 98.6, o2Sat 100% RA. She denies medical history, meds, or allergies. Upon exam, she has mild diffuse tenderness along the arch and heel of each foot. She has no deformity, no signs of infection, and no masses palpable. Pain is worsened by dorsiflexing the toes, What is the most appropriate option for this patient? A. Acetaminophen as needed B. Switch to thick-soled tennis sneakers. C. Lidocaine injections into heel D. NSAIDs and cessation from ballet until symptoms improve.

D. NSAIDs and cessation from ballet until symptoms improve. The patient is experiencing planter fasciitis, an extremely common cause of pain in the sole of the foot. It is common in ballet dancers especially and is worsened by their thin-soled shoes. Exam reveals tenderness along the plantar fascia without deformity or mass that is worsened with dorsiflexion of the does. It is especially noted when the patient starts walking or running. X-rays are not needed to diagnose this condition.

A 65 yo female presents to discuss her bilateral knee pain due to osteoarthritis. She has been using acetaminophen 1000 mg TID as well as other NSAIDs as needed. One of her friends has been taking glucosamine chondroitin, and she wants your advice regarding that medication. Her friend also received a hyaluronic acid injection with good relief. She also heard about a new injection with stem cells and would like your opinion. What evidence-based recommendations can you give her? A. Some evidence shows that stem cell injections are beneficial. B. Glucosamine chondroitin is beneficial but should be avoided in shellfish allergy. C. Hyaluronic acid injections can be recommended for most patients. D. Non-impact activities with weight loss in patients with BMI >25kg/m 2 are recommended.

D. Non-impact activities with weight loss in patient with a BMI >25 kg are recommended. Explanation: Persons with symptomatic knee osteoarthritis should participate in self-management programs, strengthening, low-impact aerobic exercise, and neuromuscular education (SOR: strong). Weight loss can be recommended as well if BMI >25 (SOR: moderate). Recommended pharmacologic therapies include oral or topical nonsteroidal anti-inflammatory drugs or tramadol )SOR: Strong. No recommendation can be made for an against the use of acetaminophen, opioids, or pain patches (SOR: inconclusive). (A) Stem cell therapies are more recent, and there is not enough evidence and research to recommend them at this time. (B) Acupuncture, glucosamine, and chondroitin are not recommended therapies for knee osteoarthritis (SOR: strong). (C) Hyaluronic acid injections are not recommended (SOR: strong), and evidence to support corticosteroid injections is inconclusive.

A 58 yo male presents for right knee effusion. He denies trauma or injury but has had some knee pain in the past. He work up with a swollen knee and pain this morning. He has no fever or chills. On exam, in addition to the 3+ effusion, he has generalized tenderness and minimal range of motion (20 degrees). You perform an arthrocentesis and obtain the following findings: Color is yellow, clarity is transparent, viscosity is high, WBC per mm3 are 1,500, PMNs are 20%. What is the likely diagnosis? A. Septic arthritis B. Rheumatoid arthritis C. Lupus arthritis D. Osteoarthritis

D. Osteoarthritis Explanation: A patient has an non-traumatic knee effusion. Therefore, infection or inflammatory causes should be ruled out. He has no fever, but fever is not always present in septic arthritis. Synovial fluid findings in osteoarthritis usually suggest a minimally inflammatory or noninflammatory process with a WBC <2000/mm3. Crystals are absent when examined using compensated polarized light microscopy. The patient's synovial fluid analysis is more consistent with effusion related to osteoarthritis. Films may be helpful by showing some joint space narrowing, subchondral bony sclerosis and or cyst as well as osteophytes. Inflammatory causes like rheumatoid arthritis, lupus arthritis, or gout usually present with opaque synovial fluid, high proteins, WBC between 2,000 and 50, 000 and PMNs >50%. Gram stain and culture are negative.

A 21 yo rugby player had a sudden onset of chest pain after tackling an opposing player. He denies any dyspnea. He has no history of health problems or surgeries. On physical exam, he has no pain or deformity in his clavicle. His rotator cuff muscles are intact. He has an easily seen and palpable defect in the muscle belly of his chest inferior to his clavicle. What is the most likely diagnosis? A. Myocardial infarction B. Manubrium fracture C. Pneumothorax D. Pectoral muscle tear

D. Pectoral muscle tear Explanation: This is a common mechanism of injury for a pectoral muscle tear. A visible defect in the muscle belly helps guide the diagnosis. Complete tears mainly occur at the humeral insertion and require surgical repair. Partial tears my be difficult to diagnosis, but strength is affected when compared to the contralateral side.

A 15 yo male with no PMH presents with shoulder pain that has occurred for several months. He has been playing baseball for the last 3 years and began feeling pain in his left arm and shoulder when he started learning and practicing in the breaking-ball pitch over the last 6 months. He denies any trauma. Pain only occurs when the patient is pitching and is relieved by rest. Pain also tends to occur in the deceleration portion f his pitch and is relieved by rest. Pain also tends to occur in the deceleration portion of his pitch and is not related to temperature or time of the day. The patient's VS are normal. Exam shows pinpoint tenderness where the shoulder meets with the arm. What is the most likely diagnosis? A. Thoracic outlet syndrome B. Rotator cuff tendinitis C. Shoulder impingement D. Proximal humerus stress injury (little leaguer's shoulder)

D. Proximal humerus stress injury (little leaguer's shoulder) Explanation: PHS injury affects the growth plate of the proximal humerus after repeated microtrauma.

A 23 yo female otherwise healthy patient comes to clinic with c/o new onset joint pain in her right wrist since yesterday. Her right hand hurt the day before. She denies any recent trauma and denies previous wrist pain. She has no allergies and takes only OCPs. She is sexually active. She drinks less than two drinks per week and denies use of tobacco or illicit substances. She has had a recent skin rash. Based on her history, what do you suspect? A. Gout B. RA C. Osteoarthritis D. Septic arthritis

D. Septic arthritis Explanation: based on age, gender, and history of sexual activity, and skin rash, septic arthritis caused by Neisseria Gonorrhea is the most probable diagnosis. Females are more likely to develop gonococcal septic arthritis and may have no genitourinary complaints. This kind of septic arthritis is most common in young adults and presents with fever, polyarthritalgias, transient tendonitis, and can also have associated rash. Synovial fluid and blood cultures are not routinely positive. Cultures from mucous membrane site of infection should be tested (pharynx, vagina, rectum).

A 16 yo male sustained a fracture of the right humerus during a car accident. X-ray reveals extension of the fracture through the metaphysis, physis, and epiphysis of the bone. The patient undergoes open reduction to achieve proper anatomic alignment of the bone for healing. Based on the Salter-Harris classification system, which type of fracture is this? A. Type I B. Type II C. Type III D. Type IV

D. Type IV Explanation: The extent of the fracture is consistent with Type IV fracture, which requires proper anatomic alignment to heal effectively. (A) (B) Type I fractures are transverse breaks across the physis. Type II fractures, which constitute about 75& of fractures, involved the physis and metaphysis. Type I and Type II fractures are usually treated with closed reduction. (C) Type II fractures involve the physis and epiphysis in addition to the intraarticular regions associated with bone growth. Type II fractures also require proper anatomical alignment for effective healing.